Richard E. Link, MD, PhD

Richard E. Link, MD, PhD

Baylor College of Medicine

Houston, Texas

Richard E. Link, MD, PhD, is a professor and board-certified and fellowship-trained urologist specializing in the treatment of urologic disease affecting the kidney, ureter, adrenal gland and prostate. Dr. Link holds the Carlton-Smith Endowed Chair in urologic education at the Baylor College of Medicine (BCM) in Houston, Texas and directs the BCM division of endourology and minimally invasive surgery. He serves as director of living donor procurement for several major kidney transplant programs in Houston, including Baylor St. Luke’s Medical Center, Texas Children’s Hospital, and the Houston Methodist Hospital. Dr. Link focuses on the use of laparoscopic, robotic-assisted, percutaneous, and endoscopic techniques to treat kidney and prostate tumors, benign prostatic hypertrophy, renal and ureteral obstruction, and urinary tract stones and has been an early pioneer in the development of laparoendoscopic single-site donor nephrectomy.

Dr. Link earned both his MD and PhD in molecular and cellular physiology at Stanford University in California and completed an internship and residency at BCM before completing a fellowship at The Johns Hopkins University School of Medicine in Baltimore, Maryland. Dr. Link also has a strong interest in applying single site robotic technology using the da Vinci SP platform to retroperitoneal and transvesical urologic surgery. He has published numerous papers and earned many awards, including the Fulbright and Jaworski LLP Faculty Excellence Award for Teaching and Evaluation at BCM.


Talks by Richard E. Link, MD, PhD

Navigating the Shifting Landscape of Minimally Invasive Urologic Surgery in the Era of Single Site Robotics

Richard E. Link, MD, PhD, discusses the shifting landscape of minimally invasive urologic surgery in the era of single-site robotics. He describes the state of urologic minimally invasive surgery as a “messy toolbox,” with a huge diversity of technologies and techniques currently employed and a lack of consensus.

Dr. Link then ranks approaches based on invasiveness, with robotic single-port (SP) systems being the least invasive. He outlines benefits and drawbacks of various techniques and wonders if there has been a period of stagnation.

He then addresses advantages of the da Vinci SP system, with a softball-sized working envelope and a 360-degree rotation around its axis, its robotic dexterity, its ability to work through small incisions (2.7 cm), and its versatility for multi-quadrant surgery, as well as in working with extraperitoneal, retroperitoneal, and transvesical approaches. He lists disadvantages as well, including cost, scarcity, learning curve, and challenges with large specimens.

Dr. Link contends that development of the SP approach is driving an increase in extraperitoneal approaches (while laparoscopic and robotic advancements drove towards the transperitoneal approaches). He then explains the shift towards the retroperitoneal approach, which is more efficient and timesaving. Dr. Link lists anesthesia advantages of SP, including shorter procedures, lower risk of abdominal entry vascular and organ complications, less pain, and fewer incisions.

Dr. Link then explains that today the SP comprises the vast majority of his radical prostatectomies. He describes the new technology interplay between cost/availability, skills/training, patient benefits, and versatility/speed and acknowledges the tension between a new platform and a technique with which a practitioner is comfortable. Dr. Link predicts that costs will drop, availability will rise, and calls SP “the future.”

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Expanding Your Robotic Toolbox for Treating UPJ and Proximal Ureteral Obstruction: Not Everything is a Nail

Richard E. Link, MD, PhD, presents and demonstrates robotic-assisted options for the treatment of UPJ and Proximal Ureteral Obstruction (UPJO) via pyeloplasty. Dr. Link begins by exploring the history of UPJO treatment, acknowledging that pyeloplasty has only recently begun to rival endopyelotomy as a treatment option, despite the evidence supporting the long-term success of pyeloplasty over endopyelotomy.

In this presentation, Dr. Link discusses:

Patient evaluation for pyeloplasty versus endopyelotomy
Adjuncts to pyeloplasty for UPJO treatment
Case-based examples of the adjuncts in action
Robotic technology used in facilitating surgery to treat UPJO

Dr. Link concludes by urging those who are already comfortable managing primary UPJO with pyeloplasty to begin familiarizing themselves with the adjuncts to the operation. He highlights that these adjuncts are more successful for patients and more accessible to urologists now than they were in the prior decade.

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Nephron-Sparing Renal Surgery: A Deeper Dive Into How Local Recurrence Issues Alter Preoperative and Postoperative Decision-Making

Richard E. Link, MD, PhD, Professor of Urology and the Carlton-Smith Endowed Chair in Urologic Education at the Baylor College of Medicine in Houston, Texas, discusses the evolving standard of care for renal tumors, and how to determine whether someone should have nephron-sparing surgery. He provides some history, explaining that radical nephrectomy used to be standard for all patients with renal tumors, but that due to improvements in technology and technique, partial nephrectomy is now used in a large percentage of cases. Dr. Link argues that with this great power to perform partial nephrectomies on almost all renal tumors comes a great responsibility to make sure that patients receive appropriate care for their individual cases. He observes that this can be complicated for multiple reasons, including that: decision-making about suitability for nephron sparing is not solely an oncologic decision; resecting more complex tumors may be associated with higher perioperative complication risks and likely results in more renal function loss; older or sicker patients tolerate complex or more lengthy surgery less well and may be less ideal candidates; and older patients likely have less to gain from nephron-sparing due to life expectancy. Beyond those concerns, Dr. Link lists and discusses several fundamental oncologic questions to consider in determining whether a patient is a good candidate for partial nephrectomy or not. These include assessing the risk of pathologic upstaging of “resectable appearing” tumors, the impact of tumor complexity on positive margins and how positive margins after partial nephrectomy alter outcome, the risk of de novo ipsilateral second primary tumors in the future and whether pathology and stage alter this risk in some fashion, and whether the patient would benefit more from a radical nephrectomy. Dr. Link concludes that: upstaging of cT1 tumors to pT3a at partial nephrectomy is relatively rare and portends a statistically significant if rather modest negative impact on recurrence free survival; risk of upstaging appears to be higher for larger tumors, higher RENAL scores, higher grade tumors, and those with irregular morphology; renal sinus fat invasion does not appear to be higher risk for poor oncologic outcomes than perinephric fat invasion; there is little data supporting better oncologic outcomes for radical nephrectomy as compared to partial nephrectomy for completely resected pT3 renal cell carcinoma; true positive surgical margins after partial nephrectomy have a significant negative impact on oncologic outcomes; larger tumors with higher RENAL scores raise the risk of positive margins at partial nephrectomy; and since little data exists about risk of second ipsilateral primary tumor development this should not drive decision making today outside of a genetic “diagnosis.”

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Can You Drive a Stick? Prevention and Management of Bleeding During Minimally Invasive Renal Surgery

Richard E. Link, MD, PhD, Professor of Urology and the Carlton-Smith Endowed Chair in Urologic Education at the Baylor College of Medicine, discusses techniques for preventing and managing bleeding during renal surgery, emphasizing the importance of maintaining laparoscopic surgery skills that have eroded with the increased use of robotic surgery. He explains that major bleeding complications can occur during abdominal access, critical dissection steps, or during exit from the abdomen, and surgeons need to be prepared with the correct tools and skills. Dr. Link presents a two-phase system for assessing danger and formulating a plan when major bleeding occurs. Phase 1 is short-term damage control, and involves evaluation of blood loss potential, determination of whether the blood is venous or arterial in origin, and a decision on whether the surgeon can handle the bleed laparoscopically with their skill set. Phase 2 is permanent control, and features a reassessment of response to damage control and a decision on whether the bleed can be solved laparoscopically or if the surgeon should facilitate safe open conversion. Adequate assessment is key to proper management. Dr. Link explains that robotic cases should be approached similarly, but emphasizes the importance of good teamwork and being slow and deliberate when there is a bleed during a robotic surgery.

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A Better Mousetrap: Minimally-Invasive Management of Symptomatic Caliceal Diverticular Stones in the Era of Robotic Surgery

Richard E. Link, MD, PhD, Professor of Urology and the Carlton-Smith Endowed Chair in Urologic Education at the Baylor College of Medicine, discusses the pros and cons of different techniques for managing caliceal diverticular stones, a simple problem requiring a complex solution. The presentation aims to provide a framework for the identification and management of this condition since there are not enough high-quality studies to have a definitive strategy. Dr. Link discusses caliceal diverticulum incidence, etiology, and presentation, as well as the specific qualities of stones in caliceal diverticula, noting that stone formation is not caused by the presence of a caliceal diverticulum, but rather by the same metabolic anomalies experienced by other stone formers. He then dissects the different surgical options for treatment, including: extracorporeal shockwave lithotripsy (ESWL), which results in stone-free rates of ≤25% and should only be used in patients who cannot tolerate more effective therapy; ureteroscopic management, which is superior to ESWL but still has low success rates; and percutaneous management, which was the gold standard treatment before the era of robotic surgery, and results in a stone-free rate between 70 and 100%, although it can be a challenging surgery. Dr. Link also discusses laparoscopic diverticulectomy and robotic true partial nephrectomy, more aggressive approaches that may be needed if percutaneous management fails. He concludes with several case studies, emphasizing that treatments should be tailored to individual patients.

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